Ectopic Pregnancy Ultrasound

The Legal Aspect of Therapeutic Abortion in Malaysia

A 16 weeks of gestation fetus who was terminated through cervagerm insertion due to severe uncontrolled chronic hypertension that is exacerbated by pregnancy.

As a general rule, abortion is illegal in Malaysia and both parties; the mother and the provider of the service can be charged according to penal act. Exception to this is for the medical cause in which a registered doctor formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or injury to the mental or physical health of the pregnant woman, greater than if the pregnancy were terminated. Apart from this cause, it remains illegal.

As for example, a rape case alone is not an indication for the legalization of abortion. However, if the pregnant mother of a rape case develop severe mental distress in which according to medical doctor could harm her in any aspect, therefore it is legal to perform abortion.

Another issue is whether should the abortion needs consent from the patient. As a general rule, abortion performed without consent from the mother deserves a penalty charges. However, another section (section 92) can be applied to save a doctor who performed abortion with a good intention to save the mother’s live.

The indication of legal abortion in Malaysia including 1) Any medical condition that can be worsened by pregnancy. 2) A pregnancy with fetus that is unlikely to survive like anencaphaly. This is not applied to any syndrome or congenital malformation in which the baby could survive like Down syndrome. 3) A rape case in which the pregnancy causing the mental distress to the patient.

The Malaysian Medical Council regards induced non-therapeutic abortion a serious infamous conduct and if proved to the satisfaction of the Council, a practitioner is liable to disciplinary action. A criminal conviction in Malaysia or elsewhere for the termination of pregnancy in itself affords grounds for disciplinary action. (Code of Medical Ethics, Malaysian Medical Association)

 

 

Below is some penal act regarding abortion in Malaysia.

Causing miscarriage

312. Whoever voluntarily causes a woman with child to miscarry shall be punished with imprisonment for a term which may extend to three years or with fine or with both; and if the woman is quick with child, shall be punished with imprisonment for a term which may extend to seven years, and shall also be liable to fine.

Explanation—A woman who causes herself to miscarry is within the meaning of this section.

Exception—This section does not extend to a medical practitioner registered under the Medical Act 1971 [Act 50] who terminates the pregnancy of a woman if such medical practitioner is of the opinion, formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or injury to the mental or physical health of the pregnant woman, greater than if the pregnancy were terminated

Causing miscarriage without woman’s consent

313. Whoever commits the offence defined in section 312, without the consent of the woman, whether the woman is quick with child or not, shall be punished with imprisonment for a term which may extend to twenty years, and shall also be liable to fine. Death caused by act done with intent to cause miscarriage. If act done without woman’s consent

314. Whoever, with intent to cause the miscarriage of a woman with child, does any act which causes the death of such woman, shall be punished with imprisonment for a term which may extend to ten years, and shall also be liable to fine; and if the act is done without the consent of the woman, shall be punished with imprisonment for a term which may extend to twenty years

Explanation—It is not essential to this offence that the offender should know that the act is likely to cause death

Act done with intent to prevent a child being born alive or to cause it to die after birth

315. Whoever before the birth of any child does any act with the intention of thereby preventing that child from being born alive, or causing it to die after its birth, and does by such act prevent that child from being born alive, or causes it to die after its birth, shall, if such act is not caused in good faith for the purpose of saving the life of the mother, be punished with imprisonment for a term which may extend to ten years or with fine or with both.

Act done in good faith for the benefit of a person without consent

92. Nothing is an offence by reason of any harm which it may cause to a person for whose benefit it is done in good faith, even without that person’s consent, if the circumstances are  such that it is impossible for that person to signify consent, or if that personis incapable of giving consent, and has no guardian or other person in lawful charge of him from whom it is possible to obtain consent in time for the thing to be done with benefit: Provided that this exception shall not extend to—

(a) the intentional causing of death, or the attempting to cause death;

(b) the doing of anything which the person doing it knows to be likely to cause death, for any purpose other than the preventing of death or grievous hurt, or the curing of any grievous disease or infirmity;

(c) the voluntary causing of hurt, or to the attempting to cause hurt, for any purpose other than the preventing of death or hurt;

(d) the abetment of any offence, to the committing of which offence it would not extend.

ILLUSTRATIONS

(a) Z is thrown from his horse and is insensible. A, a surgeon, finds that Z requires to be trepanned. A, not intending Z’s death, but in good faith, for Z’s benefit, performs the trepan before Z recovers his power of judging for himself. A has committed no offence.

(b) Z is carried off by a tiger. A fires at the tiger, knowing it to be likely that the shot may kill Z, but not intending to kill Z, and in good faith intending Z’s benefit. A’s ball gives Z a mortal wound. A has committed no offence.

(c) A, a surgeon, sees a child suffer an accident which is likely to prove fatal unless an operation be immediately performed. There is no time to apply to the child’s guardian. A performs the operation in spite of the entreaties of the child, intending, in good faith, the child’s benefit. A has committed no offence.

(d) A is in a house which is on fire, with Z, a child. People below hold out a blanket. A drops the child from the housetop, knowing it to be likely that the fall may kill the child, but not intending to kill the child, and intending in good faith, the child’s benefit. Here, even if the child is killed by the fall, A has committed no offence.

Explanation—Mere pecuniary benefit is not benefit within the meaning of sections 88, 89 and 92.

Aetiology and Complication of Abnormal Lie

Dun like killer examiner :

2nd question: Do the same complications of unstable lie apply as well in transverse and oblique lie? e.g rupture of uterus and compund presentation

30 Sep 2011 5.30 PM

Answer

In approaching this question, we need some area of clarification for the usage of the term.. Basically, we refer all this problem as abnormal lie. Lie is defined as relationship between longitudinal axis of fetus to the longitudinal axis of maternal uterus.

Presentation is defined as part of fetal that presenting at the superior strait of the maternal pelvis. Simply put, it means, what part of fetus that appear at maternal pelvis.

Meanwhile, unstable lie is defined as the lie of fetus persistently changed at term because it is a physiological act of the baby to change it’s lie and presentation before 36 weeks. After 36 week, the normal lie is longitudinal.

Patient with unstable lie may have transverse or oblique lie during labour. Be it at term or during delivery. It may also turn back to longitudinal lie.

The most common cause for abnormal presentation is uterine laxity seen in patient with multiparity or anything that cause distension of uterus (previous multiple pregnancy, fibroid etc). Other causes includes, multiple gestation, polyhydramnios, prematurity/ wrong dating, placenta previa, fetal anomaly, uterine anomaly, pelvic mass and contracture of the uterus.

You also need to know the physiology of the growing fetus and the anatomy of the uterus. In early pregnancy, all baby have unstable lie. As the uterus getting bigger and bigger, the pear shape of the uterus make the upper space being occupy the larger part of the baby (buttock) and the lower space being occupy by the head.

However, in lax uterus, the baby may settle down it position in transverse position and it become more comfortable with that position. As the uterus and baby grow, it just fit in that position.

Polyhydramnios, prematurity multiple gestation will have this problem simply because there are a lot / bigger space in wombs that they easily turning around. (relative liquor volume in relation to fetal size)

Meanwhile, any injury/ abnormality of the uterus make the baby unable to turn into longitudinal lie and remain in their position.

Using the same principle, you may explain why baby with neural tube defect have unstable lie which basically due to the polyhydramnios.

After you understand the physiology of the baby lie and uterus anatomy, then you can explain easily the complication of the abnormal lie with regards to their aetiology.

Why did uterine rupture occur? Basically it is due to the obstructed labour in over distended uterus.

Abnormal presentation be it compound, cord, face, brow can also due to the complication of unstable lie. Because, as i mentioned earlier, presentation simply means relation of fetal part with maternal pelvis. So anything can happen but there will be certain condition that will have abnormal presentation as complication. For example, cord prolapse more common in footling breech, compound presentation more commonly occur in transverse lie and many more.

Evidence Based Approach for The Management of Asthma in Pregnancy

Picture of a pregnant woman using an inhaler taken from science library photo taken at this link [here]

Asthma is an increasingly common chronic illness in pregnancy with the prevalence may reach up to  8%. [Holland & Thomson, 2006]. Pregnancy is characterized by a physiological immunosuppression, an immunological tolerance that protects the fetus from maternal immune response against paternal antigens expressed by the fetus.  [Lilla Tamasi et al, 2011]

Physiological pregnancy has been described as a Th2-dominated state, and current studies show that a trimester dependent, pregnancy-induced increase in regulatory T cell (Tregs) number has a key role in the maintenance of maternal tolerance to paternal antigens during pregnancy, exerting an inhibition on the activation of effector T lymphocytes and NK cells. [Lilla Tamasi et al, 2011] Absence of trimester dependent regulatory T cell elevation in asthmatic pregnancy leads to impaired inhibition of T lymphocyte and NK cell activation and proliferation. Elevated numbers of activated effector T lymphocytes and NK cells may cause immune mediated alteration of fetal growth and enhancement of allergic/asthmatic response. [Lilla Tamasi et al, 2011]

Pregnancy may alter the natural course of asthma. Asthma improves during pregnancy in about one-third, remains the same in another one-third, and worsens in one-third of pregnant women. More severe asthma before pregnancy increases the risk of worsening during pregnancy, and there is a concordance between the courses of asthma during subsequent pregnancies [Lilla Tamasi et al, 2011]. Lung inflammation, smoking, obesity , altered placental function [Ross E. Rocklin, 2011] and female fetuses are also recognized risk factor for asthma exacerbation. [Lilla Tamasi et al, 2011] and poor pregnancy outcomes.

Patient may also suffers from co- morbid condition such as obesity, pregnancy-induced hypertension and gastro-oesophageal reflux. [Holland & Thomson, 2006] Asthma represents a risk factor for several maternal and fetal complications, such as asthma exacerbations, use of oral corticosteroids, hospitalizations due to asthma attacks, preeclampsia, gestational hypertension, preterm delivery, cesarean delivery, low birth weight, intrauterine growth restriction, and fetal death [Lilla Tamasi et al, 2011].

Most of the asthma exacerbation are usually mild and self limiting and rarely causing severe attack. However, if severe exacerbation occur, it will cause significant morbidity and mortality to the patient as well as the fetus.  Major risk of asthma to the mother and fetus are due to under treatment or poorly controlled disease and may be compounded by poor maternal compliance with treatment due to fears of side-effects on the unborn child [Holland & Thomson, 2006] Apart from that, Jennifer W. Mc Callister et al, has found out that there is a disparities of treatment for acute exacerbation of asthma in emergency department especially in term of systemic steroid administration.  This should not happen and pregnancy should be considered an indication for maximizing therapy during an exacerbation, rather than withholding it.

Congenital malformation may complicate maternal asthmatic exacerbation in early trimester as maternal hypoxia together with respiratory alkalosis may decrease the placental blood flow. Decreased fetal blood oxygen could result in abnormal growth and development of the fetus. Furthermore, maternal hypoxia has been found to be associated with an increased risk of cleft lip and palate in mice.[ Lucie Blais & Amelie Forget, 2008]

Short acting beta 2 agonist (SABA) is safe eventhough it is previously being said that the usage of this agent will increase the risk of developing pregnancy induced hypertension. The explaination laid behind this hypothesis was that the inhaled SABA will enter the systemic circulation and cause vasodilation of the blood vessel. This will then cause reduction in diastolic blood pressure and cause reflex tachycardia. Study by Marie-Jose´e Martel et al however shows that inhaled SABA actually reduced the risk of PIH and the use of this medication is safe throughout pregnancy. The reasons for the previous hypothesis of relation between SABA-PIH could be due to some reason including  smoking and masking effect of SABA that reduce the diastolic blood pressure, hence lead to under diagnosed of PIH. The usage of SABA alone is safe, however, it should be pointed out that all patients with persistent asthma require a controller medication such as an inhaled steroid [R.E. Rocklin et al, 2011]

Long-acting Beta 2 agonists are now recommended to be used in conjunction with inhaled steroids. The use of these long-acting bronchodilators as monotherapy was reported in one study that did not find any evidence of an effect on fetal growth in humans [R.E. Rocklin et al, 2011]

The usage of high dose ICS may increase the risk of congenital malformation if use in the first trimester. Lucie Blais et al in her study observed that women who took high doses of ICSs during the first trimester of pregnancy were 63% more likely to have a baby with a congenital malformation than women taking low to moderate doses of ICSs. However, low to moderate dose of ICS is safe. Furthermore, current asthma guidelines recommend ICSs for the management of all levels of persistent asthma during pregnancy and recommend that pregnant women be treated as aggressively as nonpregnant women to achieve and maintain control of asthma.  [Marie-Claude Breton et al, 2010] The risk of perinatal mortality was not found to be significantly associated with ICS use during pregnancy. The result associated with higher doses of ICSs is limited due to a lack of statistical power and a possibility of residual confounding by asthma severity and  control. [Marie-Claude Breton et al, 2010] Furthermore, a trend towards higher Treg cell prevalence was observed compared to those with inadequate adherence to ICS treatment. [Lilla Tamasi et al, 2011] Therefore, asthmatic pregnant women should be managed with the minimum effective ICS dose. But if higher doses of ICSs are needed to control asthma, their benefits outweigh their risks. [Marie-Claude Breton et al, 2010]

The usage of oral corticosteroid previously being said to be associated with increase risk of congenital malformation particularly cleft lip, cleft palate or both. However, observation by Lucie Blais & Amelie Forget in their study shows that women who had an asthma exacerbation but who did not fill a prescription for oral corticosteroids were 2 times more likely to have a baby with a major congenital malformation than women who did not have an exacerbation. It is found that the hypothesis that link between the usage of oral corticosteroid and congenital malformation are weak. Study by Ludmila N. Bakhireva et al, demonstrate that the usage of systemic corticosteroid may resulting in deficit of about 200 g in birthweight compared with controls and exclusive B2-agonist users. However, the result is not significant to suggest that the usage of this agent impair fetal growth and it use should be weighed against the necessity to control severe asthma.

Chromones such as cromolyn and nedocromil have an anti inflammatory activity but due to their relatively limited efficacy, it should only be used in mild persistent asthma and recommended as alternative medication only.

Leukotriane modifiers such as leukotriene receptor antagonists (montelukast and zirfirlukast) and 5-lipoxygenase pathway inhibitors (zileuton) are not preferred as treatment option in mild persistent asthma in pregnancy.

Theophylline that has bronchodilating activity and mild anti inflammatory properties are safe to be used in pregnancy but it is considered as alternative treatment and not the preferred therapy

In managing severe acute asthma, Oral corticosteroid should not be witheld. The British Thoracic society guidelines has clearly stated that the medical management of asthma in pregnant and non pregnant mother are same. Volume resuscitation should be considered as there would be a volume deplition due to combination of hyperventilation and intercurrent sepsis despite of difficulty in accessing the fluid balance. Central venous access is impractical and potentially dangerous in severe asthmatic. Regional anesthesia especially epidural is more preferred than general anesthesia  if patient required operative delivery or as pain management as it reduce hyperventilation and stress response to the pain. However, judgement should be made clearly as regional anesthesia would be impractical in patient who are severely breathless and precipitate deterioration of lung function due to loss of intercostal muscle function

Apart from that, education about asthma, life style modification and smoking cessation should be encourage to the patient. Main education topic should includes information about the disease, use of inhaler devices, adherence to treatment and importance of regular visit, environmental control measure to reduce exposure to allergens and irritants and self treatment action plan. [Lilla Tamasi et al, 2011].

Reference:

1)         Faranak Firoozi, Catherine Lemiere, Francine M. Ducharme et al, "Effect of maternal moderate to severe asthma on perinatal outcomes", Respiratory Medicine (2010) 104, 1278- 1287

2)         Jennifer W. McCallister, Cathy G. Benninger, Heather A. Frey, et al, "Pregnancy related treatment disparities of acute asthma exacerbations in the emergency department", Respiratory Medicine (2011) 105, 1434-1440

3)         Lilla Tamasi, Ildiko´ Horvath, Aniko Bohacs et al, " Asthma in pregnancy e Immunological changes and clinical management", Respiratory Medicine (2011) 105, 159-164, Elsevier

4)         Lucie Blais & Amelie Forget, "Asthma exacerbations during the first trimester of pregnancy and the risk of congenital malformations among asthmatic women", J Allergy Clin Immunol 2008;121:1379-84

5)         Lucie Blais, Marie-France Beauchesne, Catherine Lemie` & Naoual Elftouh, "High doses of inhaled corticosteroids during the first trimester of pregnancy and congenital malformations", J Allergy Clin Immunol 2009;124:1229-34.

6)         Ludmila N. Bakhireva, Kenneth Lyons Jones, Michael Schatz et al, "Asthma medication use in pregnancy and fetal growth", J Allergy Clin Immunol 2005;116:503-9.)

7)         Marie-Claude Breton,, Marie-France Beauchesne, Catherine Lemie, et al, "Risk of perinatal mortality associated with inhaled corticosteroid use for the treatment of asthma during pregnancy", J Allergy Clin Immunol 2010;126:772-7.

8)         Marie-Jose´e Martel, E´ velyne Rey, Marie-France Beauchesne, et al "Use of short-acting b2-agonists during pregnancy and the risk of pregnancy-induced hypertension", J Allergy Clin Immunol 2007;119:576-82

9)         Ross E. Rocklin, "Asthma, asthma medications and their effects on maternal/fetal outcomes during pregnancy", Reproductive Toxicology 32 (2011) 189–197

10)       S. M. Holland, K. D. Thomson, "Acute severe asthma presenting in late pregnancy", International Journal of Obstetric Anesthesia (2006) 15, 75–78

to download pdf version of this paper, please click [here]

Physiological Immunosuppression in Pregnancy

Diclaimer: This is not written by blog author but rather taken from:  Lilla Tamasi, Ildiko´ Horvath, Aniko Bohacs et al, " Asthma in pregnancy e Immunological changes and clinical management", Respiratory Medicine (2011) 105, 159-164, Elsevier. This note is not for the commercial use and mainly for educational purposes.

Pregnancy is characterized by a physiological immunosuppression, an immunological tolerance that protects the fetus from maternal immune response against paternal antigens expressed by the fetus.  

Physiological pregnancy has been described as a Th2-dominated state, and current studies show that a trimester dependent, pregnancy-induced increase in regulatory T cell (Tregs) number has a key role in the maintenance of maternal tolerance to paternal antigens during pregnancy, exerting an inhibition on the activation of effector T lymphocytes and NK cells.

Diminished numbers of Tregs in pregnancy were associated with immunological rejection of the fetus as well as preeclampsia and low fetal birth weight.

Of note, Tregs exert inhibitory effects on natural killer lymphocytes responsible for protection against viruses that may contribute to increased susceptibility to viral infections (e.g. influenza) during pregnancy.